Chest imaging includes use of plain x-rays, computed tomography (CT) scanning, magnetic resonance imaging (MRI), nuclear scanning, including positron emission tomography (PET) scanning, and ultrasonography.
There are no absolute contraindications to undergoing noninvasive imaging procedures except for MRI. The presence of metallic objects in the patient's eye or brain precludes MRI.
Presence of a permanent pacemaker or internal cardioverter-defibrillator is a relative contraindication (see MRI Safety). Additionally, gadolinium, when used as a contrast agent for MRI, increases risk of nephrogenic systemic fibrosis Contrast reactions Sagittal T1-weighted image of the brain shows normal midline structures. Sagittal proton density–weighted 3-tesla magnetic resonance image of the right knee shows meniscocapsular separation... read more in patients with stage 4 or 5 chronic kidney disease or those receiving dialysis. Gadolinium may be harmful to the fetus and is generally avoided in pregnancy.
X-ray techniques that are used to image the chest include
High-resolution and helical (spiral) CT
Plain chest x-rays and fluoroscopy are used to provide images of the lungs and surrounding structures.
Plain chest x-rays provide images of structures in and around the thorax and are most useful for identifying abnormalities in the heart, lung parenchyma, pleura, chest wall, diaphragm, mediastinum, and hilum. They are usually the initial test done to evaluate the lungs.
The standard chest x-ray is taken from back to front (posteroanterior view) to minimize x-ray scatter that could artifactually enlarge the cardiac silhouette and from the side of the thorax (lateral view). Lordotic or oblique views can be obtained to evaluate pulmonary nodules or to clarify abnormalities that may be due to superimposed structures, although chest CT provides more information and has largely superseded these views. Lateral decubitus views may be used to distinguish free-flowing from loculated pleural effusion, but CT or ultrasonography can provide more information. End-expiratory views can be used to detect small pneumothoraxes.
Screening chest x-rays are often done but are almost never indicated; one exception is in asymptomatic patients with positive tuberculin skin test results, in whom a single posteroanterior chest x-ray without a lateral view is used to make decisions regarding additional diagnostic studies and/or treatment for pulmonary tuberculosis Tuberculosis (TB) Tuberculosis (TB) is a chronic, progressive mycobacterial infection, often with a period of latency following initial infection. TB most commonly affects the lungs. Symptoms include productive... read more . Chest x-rays taken with portable machines (usually anteroposterior views) are almost always suboptimal and should be used only when patients are too ill to be transported to the radiology department.
Chest fluoroscopy is the use of a continuous x-ray beam to image movement. It is useful for detecting unilateral diaphragmatic paralysis. During a sniff test, in which the patient is instructed to forcibly inhale through the nose (or sniff), a paralyzed hemidiaphragm moves cranially (paradoxically) while the unaffected hemidiaphragm moves caudally.
CT defines intrathoracic structures and abnormalities more clearly than does a chest x-ray. Conventional (planar) CT provides multiple 10-mm–thick cross-sectional images through the thorax. Its main advantage is wide availability. Disadvantages are motion artifact and limited detail from volume averaging of tissue within each 10-mm slice.
Chest CT is normally done at full inspiration. Aeration of the lungs during imaging provides the best views of the lung parenchyma, airways, and vasculature, and of abnormal findings such as masses, infiltrates, or fibrosis.
High-resolution CT (HRCT) provides 1-mm–thick cross-sectional images. HRCT is particularly helpful in evaluating
Interstitial lung diseases (eg, lymphangitic carcinomatosis, sarcoidosis Sarcoidosis Sarcoidosis is an inflammatory disorder resulting in noncaseating granulomas in one or more organs and tissues; etiology is unknown. The lungs and lymphatic system are most often affected, but... read more , idiopathic pulmonary fibrosis Idiopathic Pulmonary Fibrosis Idiopathic pulmonary fibrosis (IPF), the most common form of idiopathic interstitial pneumonia, causes progressive pulmonary fibrosis. Symptoms and signs develop over months to years and include... read more [fibrosing alveolitis])
Obtaining HRCT images at full expiration as well as full inspiration can help. Expiratory imaging can document air trapping, which is typical of obliterative bronchiolitis and other airway diseases. Images obtained with the patient in the prone position can help differentiate dependent atelectasis Atelectasis Atelectasis is collapse of lung tissue with loss of volume. Patients may have dyspnea or respiratory failure if atelectasis is extensive. They may also develop pneumonia. Atelectasis is usually... read more (which changes with changes in body position) due to lung disorders that cause ground-glass attenuation in the dependent posterior parts of the lungs, which persists despite changes in patient position (eg, fibrosis due to idiopathic pulmonary fibrosis Idiopathic Pulmonary Fibrosis Idiopathic pulmonary fibrosis (IPF), the most common form of idiopathic interstitial pneumonia, causes progressive pulmonary fibrosis. Symptoms and signs develop over months to years and include... read more , asbestosis Asbestosis Asbestosis is a form of interstitial pulmonary fibrosis caused by asbestos exposure. Diagnosis is based on history and chest x-ray or CT findings. Treatment is supportive. (See also Overview... read more , or systemic sclerosis Systemic Sclerosis Systemic sclerosis is a rare chronic disease of unknown cause characterized by diffuse fibrosis and vascular abnormalities in the skin, joints, and internal organs (especially the esophagus... read more ).
Helical (spiral) CT provides multiplanar images of the entire chest as patients hold their breath for 8 to 10 seconds while being moved continuously through the CT gantry. Helical CT is thought to be at least equivalent to conventional CT for most purposes. Its main advantages are speed, less radiation exposure, and an ability to construct 3-dimensional images. Software can also generate images of bronchial mucosa (virtual bronchoscopy). Its main disadvantages are less availability and the requirement for breath-holding, which can be difficult for patients with symptomatic pulmonary disease. Newer multidetector CT technology allows more rapid scanning of the entire chest with imaging of thin slices at high resolution.
CT angiography uses a bolus of IV radiopaque contrast agent to highlight the pulmonary arteries, which is useful in diagnosis of pulmonary embolism Pulmonary Embolism (PE) Pulmonary embolism (PE) is the occlusion of pulmonary arteries by thrombi that originate elsewhere, typically in the large veins of the legs or pelvis. Risk factors for pulmonary embolism are... read more . Contrast agent load is comparable to that with conventional angiography, but the test is quicker and less invasive. Several studies have confirmed CT angiography provides sufficient accuracy for the detection of pulmonary emboli, so it has largely replaced conventional pulmonary angiography and, except in patients unable to tolerate contrast agents, ventilation/perfusion (V/Q) scanning.
Magnetic Resonance Imaging
MRI has a relatively limited role in pulmonary imaging but is preferred over CT in specific circumstances, such as assessment of
Superior sulcus tumors
Lesions that abut the chest wall
In patients with suspected pulmonary embolism Pulmonary Embolism (PE) Pulmonary embolism (PE) is the occlusion of pulmonary arteries by thrombi that originate elsewhere, typically in the large veins of the legs or pelvis. Risk factors for pulmonary embolism are... read more in whom IV contrast agents cannot be used, MRI can sometimes identify large proximal emboli but usually is limited in this disorder.
Advantages include absence of radiation exposure, excellent visualization of vascular structures, lack of artifact due to bone, and excellent soft-tissue contrast.
Disadvantages include respiratory and cardiac motion, the time it takes to do the procedure, the expense of MRI, and the occasional presence of contraindications, which include many implanted devices and certain metallic foreign bodies. Gadolinium contrast may be harmful to the fetus, so use of contrast is usually avoided in pregnancy.
Ultrasonography is often used to facilitate procedures such as thoracentesis How To Do Thoracentesis Thoracentesis is needle aspiration of fluid from a pleural effusion. It may be done for diagnosis and/or therapy. Diagnostic thoracentesis Indicated for almost all patients who have pleural... read more and central venous catheter insertion Central Venous Catheterization A number of procedures are used to gain vascular access. Most patients’ needs for IV fluid and drugs can be met with a percutaneous peripheral venous catheter. If blind percutaneous placement... read more .
Ultrasonography is also very useful for evaluating presence and size of pleural effusions Pleural Effusion Pleural effusions are accumulations of fluid within the pleural space. They have multiple causes and usually are classified as transudates or exudates. Detection is by physical examination and... read more and is now commonly used at the bedside to guide thoracentesis. Bedside/point-of-care ultrasonography can be used to diagnose pneumothoraxes and is becoming more widely used as an extension of the physical examination.
Endobronchial ultrasonography (EBUS) is increasingly being used in conjunction with fiberoptic bronchoscopy to help localize masses and enlarged lymph nodes. Diagnostic yield of transbronchial lymph node aspiration is higher using EBUS than conventional unguided techniques.
Nuclear scanning techniques used to image the chest include
Ventilation/perfusion (V/Q) scanning
Positron emission tomography (PET)
V/Q scanning uses inhaled radionuclides to detect ventilation and IV radionuclides to detect perfusion. Areas of ventilation without perfusion, perfusion without ventilation, or matched increases and decreases in both can be detected with 6 to 8 views of the lungs.
V/Q scanning is most commonly used for diagnosing pulmonary embolism Pulmonary Embolism (PE) Pulmonary embolism (PE) is the occlusion of pulmonary arteries by thrombi that originate elsewhere, typically in the large veins of the legs or pelvis. Risk factors for pulmonary embolism are... read more but has largely been replaced by CT angiography. However, V/Q scanning is still indicated in the diagnostic evaluation for chronic thromboembolic pulmonary hypertension Pulmonary Hypertension Pulmonary hypertension is increased pressure in the pulmonary circulation. It has many secondary causes; some cases are idiopathic. In pulmonary hypertension, pulmonary vessels become constricted... read more .
Split-function ventilation scanning, in which the degree of ventilation is quantified for each lobe, is used to predict the effect of lobar or lung resection on pulmonary function; postsurgical forced expiratory volume in 1 second (FEV1) is estimated as the percentage of uptake of ventilation tracer in the healthy fraction of the lungs multiplied by preoperative FEV1 (in liters). A value of < 0.8 L (or < 40% of that predicted for the patient) indicates limited pulmonary reserve and a high likelihood of unacceptably high perioperative morbidity and mortality.
Positron emission tomography (PET)
PET uses radioactively labeled glucose (fluorodeoxyglucose) to measure metabolic activity in tissues. It is used in pulmonary disorders to determine
Whether lung nodules or mediastinal lymph nodes harbor tumor (metabolic staging)
Whether cancer is recurrent in previously irradiated, scarred areas of the lung
PET is superior to CT for mediastinal staging because PET can identify tumor in normal-sized lymph nodes and at extrathoracic sites, thereby decreasing the need for invasive procedures such as mediastinoscopy Mediastinoscopy and Mediastinotomy Mediastinoscopy is a procedure in which an endoscope is introduced through the suprasternal notch into the mediastinum to allow visualization of it. Mediastinotomy is surgical opening of the... read more and needle biopsy Transthoracic Needle Biopsy Transthoracic needle biopsy of thoracic or mediastinal structures uses a cutting needle to aspirate a core of tissue for histologic analysis. Transthoracic needle biopsy is done to evaluate... read more .
Current spatial resolution of PET is 7 to 8 mm; thus, the test is not useful for lesions < 1 cm. PET reveals metastatic disease in up to 14% of patients in whom it would not otherwise be suspected. The sensitivity of PET (80 to 95%) is comparable to that of histologic tissue examination. False-positive results can occur with inflammatory lesions, such as granulomas. Slowly growing tumors (eg, bronchoalveolar carcinoma, carcinoid tumor, some metastatic cancers) may cause false-negative results.
Newer combined CT-PET scanners are commonly used for lung cancer diagnosis and staging.